The effect of surgical approach in total knee replacement on outcomes. An analysis of 875,166 elective operations from the National Joint Registry for England,Wales, Northern Ireland and the Isle of Man

BackgroundTotal knee replacement (TKR) is clinically and cost-effective. The surgical approach employed influences the outcome, however there is little generalisable and robust evidence to guide practice. We compared outcomes between the common primary TKR surgical approaches.Methods875,166 primary TKRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient reported outcome measures (PROMs) data, with up to 15.75 years follow-up were analysed. There were 10 surgical approach groups: medial parapatellar, midvastus, subvastus, lateral parapatellar, ‘other’ and their minimally invasive versions. Survival methods were used to compare revision rates and 45-day mortality. Groups were compared using Cox proportional hazards regression and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, TKR fixation, year of primary, body mass index, and for mortality, deprivation and Charlson comorbidity subgroups. PROMs were analysed with regression modelling or non-parametric methods.ResultsThe conventional midvastus approach was associated with lower revision rates (Hazard Rate Ratio (HRR) 0.80 (95% CI 0.71–0.91) P = 0.001) and the lateral parapatellar with higher revision rates (HRR 1.35 (95% CI 1.12–1.63) P = 0.002) compared to the conventional medial parapatellar approach. Mortality rates were similar between approaches. PROMs showed statistically significant, but not clinically important, differences.ConclusionsThere is little difference in PROMs between the various surgical approaches in TKR with all resulting in good outcomes. However, the conventional midvastus approach (used in 3% of cases) was associated with a 20% reduced risk of revision surgery compared to the most commonly used knee approach (the conventional medial parapatellar: used in 91.9% of cases). This data supports the use of the midvastus approach and thus surgeons should consider utilising this approach more frequently. Minimally invasive approaches did not appear to convey any clinical advantage in this study over conventional approaches for primary TKR.     

Unexpected death in a young child associated with anomalous aortic origin of the left main coronary artery without physical exertion: A case of an anomalous coronary artery with highly abundant elastic fibers

Sudden death due to anomalous aortic origin of a coronary artery is far less common among young children in the absence of exercise stress. This report describes the case of a 2-year-old boy with a lower respiratory tract infection who suffered sudden cardiac arrest in his bed at home. The autopsy revealed that the left coronary artery (LCA) originated from the right sinus of Valsalva with an acute angle takeoff and traveled between the aorta and the pulmonary trunk (an interarterial course). Upon histological examination, the LCA, before reaching its major branches, was located adjacent to the outside of the aortic wall without an intramural passage, and the arterial wall was composed almost exclusively of elastic fibers without media containing smooth muscle cells throughout the entire length of the abnormal running. Screening tests for respiratory virus infection detected enterovirus in the lung tissue. In association with an acute angle takeoff and interarterial course, the wall structure with highly abundant elastic fibers that are more flexible tissues among blood vessel components might suggest their vulnerability to compression during the great vessels’ systolic expansion in the sympathetic activation induced by the viral infection, leading to fatal myocardial ischemia without physical exertion.     

Endoscopic coblation treatment for congenital pyriform sinus fistula in children

Congenital pyriform sinus fistula (CPSF) is a very rare branchial apparatus malformation. Traditional open surgery for fistulectomy might fail to excise the lesion completely, leading to continual recurrence. Herein, we report our experience of endoscopic coblation technique for treatment of CPSF in children.To observe the clinical efficacy of endoscopic coblation treatment of CPSF in children, especially for those in acute infection stage.Retrospective case series with 54 patients (including 20 cases in acute infection stage and 34 cases in non infection stage) who were diagnosed with CPSF between October 2017 to November 2019, all patients were treated with endoscopic coblation to close the piriform fossa fistula, neck abscess incision and drainage performed simultaneously for acute infection stage cases. Data collected including age of diagnosis, presenting symptoms, diagnostic methods, prior and subsequent treatments, length of hospitalization, and recurrence were analyzed.Of the 20 cases in acute infection stage, there were 3 children with transient vocal cord paresis all of which resolved with 1 month. Four children of the 34 cases in non infection stage appeared reddish swelling of the neck on the 4th, 5th, 6th, and 7th days after coblation and then underwent abscess incision and drainage. All cases experienced no recurrence, vocal cord paralysis, pharyngeal fistula and massive hemorrhage after their first endoscopic coblation of the sinus tract in the follow up of 3 to 28 months.Endoscopic coblation is an effective and safe approach for children with CPSF, neck abscess incision and drainage could be performed simultaneously in acute infection stage. We advocate using this minimally invasive technique as first line of treatment for CPSF.     

Advantages of an Anterior-Based Muscle-Sparing Approach in Transitioning From a Posterior Approach for Total Hip Arthroplasty: Minimizing the Learning Curve

BackgroundEnthusiasm for anterior-based approaches for total hip arthroplasty (THA) continues to increase but there is concern for increased complications during the learning curve period associated. This study aimed to investigate if there was a difference in perioperative variables, intraoperative and immediate postoperative complications, or patient-reported outcomes when transitioning from a mini-posterior approach (mPA) to an anterior-based muscle-sparing (ABMS) approach for THA.MethodsRetrospective cohort study on the first 100 primary THA cases (n = 96 patients) of the senior author (August 2016 to August 2017) using the ABMS approach. These cases were compared to primary THA cases done the year prior (July 2015 to July 2016, n = 91 cases in 89 patients) using an mPA. Data were extracted and analyzed via gamma regression with robust standard errors and using generalized estimating equation regression.ResultsWe found no difference in the estimated blood loss (P = .452) and surgical time (P = .564) between the cohorts. The ABMS cases had a slightly shorter length of stay (P = .001) with an adjusted mean length of stay of 1.53 days (95% confidence interval 1.4-1.6) compared to 1.85 days (95% confidence interval 1.8-1.9) in the mPA cases. There was no difference in the frequency of immediate postoperative complications (all, P > .05). There was no difference in the adjusted mean change in patient-reported outcomes (all P > .05). In the ABMS group, there was no difference in surgical time or physical function computerized adaptive test between the first 20 cases (reference) and each subsequent group of 20 cases (all P > .05).ConclusionThis study demonstrates no associated learning curve for an experienced senior surgeon when switching routine THA approach from mPA to ABMS. We advise careful interpretation of our results, as they may not apply to all surgeons and practices.Level of EvidenceLevel III Therapeutic Study: retrospective comparative study.     

A systems approach to forensic science applied in the military domain

Forensic science is undertaken in support of law enforcement investigations, criminal justice prosecutions, intelligence, and military objectives. There are different forensic operating models to meet these various objectives and no unified approach to forensic science has been described. There are common challenges in the military domain, which impacts the delivery of forensic science, including: different terminology between organizations, complex operating environments, operating siloes, inward-looking military structures, quality management, and resource constraints. One solution to these challenges is to apply modern organizational theory to military-focused forensic science. Organizational theory is the study of organizations in a structural sense, including objectives, people, structure and management. The modern organizational theory systems approach describes how organizations should be viewed as systems within larger systems. In the work presented in this paper, a systems approach has been applied, for the first time, to military forensic exploitation to address the common issues faced by military organizations. The advantages of applying a systems approach to military forensic exploitation are that it is applicable across forensic science organizations, it is flexible and scalable to meet the changing external environment, and it articulates the redundancies in the system to help address system failures.     

Enhancing the knowledge and skills of smallholders to adopt market-oriented tree management practices: lessons from Master TreeGrower training courses in Indonesia

ABSTRACT

Growing trees on farmland continues to be a promising land-use option for smallholders in Indonesia as they look to diversify their enterprises beyond the main agricultural sector. While most smallholders integrate trees into their farming systems, selling timber and other tree products has usually been infrequent and opportunistic. Because of this infrequent trade, most smallholders rarely adopt silvicultural practices that would increase the commercial value of their trees. A research project trialled an alternative approach to forestry extension in Indonesia, known as the Master TreeGrower (MTG) training course. The MTG training courses used a farmer-centred approach to teach smallholders about forest science and took participants to market hubs so they could better understand how different forest products were valued by traders. The MTG training approach was trialled in 2014 in five districts in Indonesia and involved 118 smallholders and 27 non-farmers as course participants. This article reports on a recent evaluation of the MTG training courses held about three years earlier to explore the enduring impacts of the training approach and whether it can be scaled-out to other areas of Indonesia. The evaluation data were collected via focus group discussions (FGDs), in-depth interviews, household surveys and observations at three project sites: Pati (Central Java), Gunungkidul (Yogyakarta) and Bulukumba (South Sulawesi). A questionnaire was distributed among the participants of the FGDs to assess the extent different knowledge and skills of tree management that had been adopted by them following the MTG courses. The evaluation of the MTG approach revealed that the courses were effective in increasing smallholders’ knowledge of commercial forestry and their silvicultural skills. Many participants were more active with silviculture and planned to invest further in commercial forestry following the MTG training. In effect, the MTG training appeared to change the hearts and minds of the farmers about how commercial forestry could enhance their livelihoods.